Medicaid work rules are needed

RALEIGH — If government gives you a cash handout or a “free” service and you are capable of working, studying, or providing service to the community in exchange for your public assistance, should you be obligated to do so?

Most conservatives say yes. Most progressives say no. Most Americans agree with the conservatives on this, much to the dismay of the progressives.

This is not a theoretical question here in North Carolina. A couple of years ago, the administration of former Gov. Pat McCrory instituted a requirement that recipients of the Supplemental Nutrition Assistance Program — or SNAP, what used to be called food stamps — had to comply with a work requirement as long as they were able-bodied and didn’t have dependent children.

Also a couple of years ago, McCrory and the North Carolina General Assembly fashioned a reform plan to introduce more managed care within the state’s Medicaid program. One element of the resulting Medicaid waiver submitted to the federal government was a proposed work requirement for North Carolina recipients — again, for those whose health conditions and caregiving responsibilities would allow it.

Responding to several applications, including ours, the U.S. Department of Health and Human Services has just ruled that states can institute Medicaid work requirements. Within hours, Kentucky became the first state to do so.

There is a robust policy debate about the efficacy of work mandates. Do they cost more to administer than they save in benefits paid? How many welfare recipients are truly capable of working? What if jobs are hard to find? What other activities — enrollment in job training, for example, or volunteering — ought to satisfy the requirement?

These are important questions. But to me, there is a more fundamental principle at stake. If the government is to be in the public-assistance business at all, the strongest case for support involves the aged, the infirm, the disabled, and orphaned children. These are individuals who can’t take care of themselves, at least not to a large degree.

Their relatives ought to be their primary caregivers. That’s what family is for. But in cases where family resources and private philanthropy are insufficient, most North Carolinians support not just a temporary safety net but long-term public assistance.

For able-bodied people who don’t fit these categories, most people see government’s proper role as much more limited. Whatever temporary assistance might be rendered, they should be moved as rapidly as possible into work, self-sufficiency, and self-respect. A combination of time limits and work requirements is necessary to combat welfare dependency, which otherwise saps initiative, unravels families and communities, and creates multi-generational cycles of poverty.

If work-or-service requirements for able-bodied Medicaid recipients are too hard to define or costly to administer, then that becomes a strong argument not to allow such recipients on Medicaid in the first place — at least not in a free society where government is supposed to be minimized, personal freedom is supposed to be maximized, and personal responsibility is supposed to be the default, not merely an aspiration.

Medicaid is the primary welfare program in the United States. It is far larger and more expensive than cash assistance, SNAP, or public housing. It is one of the fastest-growing expenses in federal and state budgets. If work requirements don’t apply to Medicaid, then the full potential of welfare reform will never be realized.

Because North Carolina has not liberalized its eligibility standards under the Affordable Care Act, we don’t have very many Medicaid recipients who’d be subject to work requirements. Still, as we know, North Carolina Democrats and progressive activists desperately want Medicaid expansion to happen.

I truly think it would be a prudent decision if they dropped their opposition to work requirements and cooperated with Republicans in devising some sensible rules. That would undercut one of the main arguments conservatives have used, so far successfully, to rebut the special-interest pressure (primarily from hospitals) to expand Medicaid.

That’s what I think the Left should do. That’s not what I think the Left will do.